NURS 267 Med-Surg Mona Hernandez Feedback Log & Score Pneumonia7/22/2020
Feedback Log & Score — Mona Hernandez Jul 11, 2020 08:35 AM
Date of
... [Show More] Completion
Jul 11, 2020 08:35 AM
Mona Hernandez
Age:
72 years
Diagnosis: Pneumonia
Score
0
1
0
94%
Feedback Log
0:00 You arrived at the patient's side.
0:00 You reviewed the patient information.
0:00 You reviewed the patient log.
0:00 You reviewed the diagnostics.
0:00 You reviewed the clinical observations.
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Feedback Log & Score — Mona Hernandez Jul 11, 2020 08:35 AM
0:00 You reviewed the MAR.
0:00 You reviewed the orders.
0:00 You reviewed the intake and output.
0:06 You washed your hands. To maintain patient safety, it is important to wash your
hands as soon as you enter the room.
0:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure:
148/88 mm Hg. Respiration: 22. Conscious state: Appropriate. SpO2: 87%. Temp: 101 F
(38.2 C)
1:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure:
147/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 88%. Temp: 101 F
(38.1 C)
1:26 You introduced yourself. This was reasonable.
1:41 You identified the patient. To maintain patient safety, it is important that you
quickly identify the patient.
1:51 You asked the patient how she felt. She replied: 'I am feeling short of
breath.'
2:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure:
149/89 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 88%. Temp: 101 F
(38.1 C)
2:32 You attached the <Pulseoximeter>pulse oximeter.<> It is a good idea to
monitor the saturation and pulse here. This will allow you to reassess the patient
continuously.
2:34 You asked the patient if she had any difficulty in breathing. She replied:
'Yes, for many days, but now it is worse.'
2:50 You assisted the patient into a high sitting position. This was indicated and the
correct response to the patient's condition.
3:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure:
147/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 88%. Temp: 101 F
(38.1 C)
3:50 You asked the patient what other symptoms she had. She replied: 'I feel
tired and have some chest tightness.'
3:58 You asked the patient: How would you describe your coughing? Is it dry, wet, or
productive? She replied: 'There has been quite a lot to cough up the last
couple of days. It is worse in the morning.'
4:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure:
149/89 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 88%. Temp: 101 F
(38.1 C)
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4:35 You educated the patient about oxygen therapy. This was reasonable.
4:56 You placed a <Nasal_oxygen>nasal oxygen cannula.<> This was part of
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shared via CourseHero.com7/22/2020 Feedback Log & Score — Mona Hernandez Jul 11, 2020 08:35 AM your orders. 4:57 You turned the oxygen on.
5:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure: 149/89 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 88%. Temp: 101 F (38.1 C)
5:16 You educated the patient about pneumonia. This was reasonable. 5:42 You educated the patient about coughing. This was reasonable.
6:04 You educated the patient about use of incentive spirometer. This was indicated by order.
6:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure: 148/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 90%. Temp: 101 F (38.1 C)
6:45 The patient used an incentive spirometer. This was indicated by order.
7:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure: 147/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 90%. Temp: 101 F (38.1 C)
7:51 You put on gloves. 8:09 You encouraged coughing. This was indicated by order.
8:10 Patient status - ECG: Sinus tachycardia. Heart rate: 119. Pulse: Present. Blood pressure: 147/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 91%. Temp: 101 F (38.1 C)
8:20 You checked the emesis basin. This was reasonable. 8:27 You removed the gloves. 8:33 You washed your hands.
9:10 Patient status - ECG: Sinus tachycardia. Heart rate: 118. Pulse: Present. Blood pressure: 148/88 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 91%. Temp: 101 F (38.1 C)
10:10 Patient status - ECG: Sinus tachycardia. Heart rate: 118. Pulse: Present. Blood pressure: 149/89 mm Hg. Respiration: 21. Conscious state: Appropriate. SpO2: 91%. Temp: 101 F (38.1 C)
10:13 You checked the <Temperature>temperature<> at the ear. The temperature was 101 F (38.1 C).
10:22 You looked for normal breathing. She is breathing at 21 breaths per minute. The chest is moving equally. Consider [Show Less]